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Menakuru SR, Dhillon VS, Atta M, Mann K, Salih A. Phenazopyridine-Induced Methemoglobinemia in a Jehovah's Witness Treated with High-Dose Ascorbic Acid Due to Methylene Blue Contradictions: A Case Report and Review of the Literature. Hematol Rep 2023; 15:325-330. [PMID: 37367083 DOI: 10.3390/hematolrep15020034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/09/2023] [Accepted: 05/15/2023] [Indexed: 06/28/2023] Open
Abstract
Methemoglobinemia is an acute medical emergency that requires prompt correction. Physicians should have a high degree of suspicion of methemoglobinemia in cases that present with hypoxemia that does not resolve with supplemental oxygenation, and they should confirm this suspicion with a positive methemoglobin concentration on arterial blood gas. There are multiple medications that can induce methemoglobinemia, such as local anesthetics, antimalarials, and dapsone. Phenazopyridine is an azo dye used over-the-counter as a urinary analgesic for women with urinary tract infections, and it has also been implicated in causing methemoglobinemia. The preferred treatment of methemoglobinemia is methylene blue, but its use is contraindicated for patients with glucose-6-phosphatase deficiency or those who take serotonergic drugs. Alternative treatments include high-dose ascorbic acid, exchange transfusion therapy, and hyperbaric oxygenation. The authors report a case of a 39-year-old female who took phenazopyridine for 2 weeks to treat dysuria from a urinary tract infection and subsequently developed methemoglobinemia. The patient had contraindications for the use of methylene blue and was therefore treated with high-dose ascorbic acid. The authors hope that this interesting case promotes further research into the utilization of high-dose ascorbic acid for managing methemoglobinemia in patients who are unable to receive methylene blue.
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Affiliation(s)
- Sasmith R Menakuru
- Department of Internal Medicine, Indiana University School of Medicine-Muncie, Muncie, IN 47306, USA
| | - Vijaypal S Dhillon
- Department of Internal Medicine, Indiana University School of Medicine-Muncie, Muncie, IN 47306, USA
| | - Mona Atta
- Department of Internal Medicine, Indiana University School of Medicine-Muncie, Muncie, IN 47306, USA
| | - Keeret Mann
- Department of Internal Medicine, Indiana University School of Medicine-Muncie, Muncie, IN 47306, USA
| | - Ahmed Salih
- Department of Internal Medicine, Indiana University School of Medicine-Muncie, Muncie, IN 47306, USA
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Methemoglobinemia Secondary to Inhalation of Automobile Emissions with Suicide Motivations. J Clin Med 2023; 12:jcm12030734. [PMID: 36769383 PMCID: PMC9917999 DOI: 10.3390/jcm12030734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 12/30/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Methemoglobinemia (MetHb) is a rare and potentially severe dyshemoglobinemia that can be induced by exposure to oxidizing agents, decreasing the functional capacity of the hemoglobin molecule to transport and release oxygen into the tissues. MetHb can originate from gases with oxidizing capacity generated by internal combustion engines, although since the universalization of catalyst converters in automobiles, a tiny proportion of MetHb poisoning is due to exposure to engine gases and fumes. Within this group, only two cases due to suicidal motivations have been reported in the last 30 years. CASE PRESENTATION Here, we expose the case of a patient with MetHb levels of 25.2% (normal 0-1.5%) who with suicidal motivations had attached and locked a hose to the exhaust pipe of her vehicle with electrical tape, becoming exposed to a sustained concentration of the vehicle's exhaust. Upon her arrival at the emergency department, the presence of generalized greyish cyanosis with alterations of the sensorium, dissociation between saturation measured by arterial blood gas analysis and pulse oximetry (98% vs. 85%), no response to high-flow oxygen therapy, and an excellent response to intravenous methylene blue treatment were highlighted. CONCLUSIONS This report illustrates an original case of acute toxic acquired MetHb due to inhalation of oxidizing substances originating from the bad ignition of an internal combustion engine. When evaluating a patient with suspected gas intoxication, we usually consider poisoning by the most common toxins, such as carbon monoxide or cyanide. In this context, we propose an algorithm to assist in the suspicion of this entity in patients with cyanosis in the emergency department. MetHb poisoning should be suspected, and urgent co-oximetry should be requested when there is no congruence between cyanosis intensity and oxygen saturation measured by pulse oximetry, if there is discordance between the results of oxygen saturation measured by arterial blood gas and pulse oximeter, and if there is no response to oxygen treatment. This algorithm could be useful to not delay diagnosis, improve prognosis, and limit potential sequelae.
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Muacevic A, Adler JR, Pathak PR, Penot AR. Phenazopyridine-Induced Methemoglobinemia: A Case Report. Cureus 2023; 15:e33715. [PMID: 36788851 PMCID: PMC9922166 DOI: 10.7759/cureus.33715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
Methemoglobinemia is a condition caused by increased methemoglobin, a reduced form of hemoglobin, in the blood. This causes the molecules to bind oxygen more tightly and decreases their ability to release that oxygen to tissue. Most cases of methemoglobinemia are acquired and occur either in pediatric populations or in individuals with predisposing conditions. This report illustrates a case of an otherwise healthy 31-year-old patient presenting to the emergency department with cyanosis of the hands and mouth and an O2 saturation of 78% after taking increased doses of the over-the-counter medication phenazopyridine. A "chocolate-brown" color of her arterial blood, and increased methemoglobin levels of 20.2%, confirmed the diagnosis of methemoglobinemia. She was treated with both methylene blue and ascorbic acid, and her oxygen saturation and serum chemistry returned to normal levels within a few hours. The case highlights the importance of discussing the dosage of all over-the-counter medications with patients and recognizing the signs and symptoms of methemoglobinemia.
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KC O, Subedi A, Sharma R, Dahal PH, Koirala M. A Case of Severe Hypoxia Caused by Phenazopyridine-Induced Methemoglobinemia: A near Fatal Event from Over-the-Counter Medication Use. Clin Pract 2022; 12:845-851. [PMID: 36412668 PMCID: PMC9680236 DOI: 10.3390/clinpract12060089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 12/14/2022] Open
Abstract
Methemoglobinemia is a rare blood disorder characterized by the oxidation of heme iron from ferrous (Fe2+) to ferric (Fe3+) state, which increases oxygen affinity and impairs oxygen release to the tissue causing hypoxia. It can be congenital or acquired; however, most cases are acquired and caused by exogenous substances such as medications, chemicals, and environmental substances. Phenazopyridine is an over-the-counter urinary analgesic medication commonly used for symptomatic relief of dysuria and has been reported to cause methemoglobinemia. However, only a handful of cases of phenazopyridine-induced methemoglobinemia have been reported. We present a case of an 89-year-old female who presented with severe hypoxia, shortness of breath, headache, nausea, and dizziness caused by phenazopyridine-induced methemoglobinemia. She was found to have a methemoglobin level of 21.5% and was treated with methylene blue, leading to a rapid improvement of her symptoms. She was taking one over-the-counter phenazopyridine 200 mg tablet three times daily for two weeks for her chronic dysuria. This case highlights the need to have a high index of suspicion of phenazopyridine-induced methemoglobinemia in a patient presenting with unexplained shortness of breath with a history of phenazopyridine use as it could lead to severe methemoglobinemia with hypoxia that could potentially be fatal if not promptly diagnosed.
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Affiliation(s)
- Ojbindra KC
- Department of Hospital Medicine, Faith Regional Health Services, Norfolk, NE 68701, USA
- Correspondence: or ; Tel.: +1-917-420-5394
| | - Ananta Subedi
- Department of Hospital Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, SD 57105, USA
| | - Rakshya Sharma
- Department of Hospital Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, SD 57105, USA
| | - Punya Hari Dahal
- Department of Hospital Medicine, Faith Regional Health Services, Norfolk, NE 68701, USA
| | - Manisha Koirala
- Department of Hospital Medicine, Faith Regional Health Services, Norfolk, NE 68701, USA
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Fadah K, Rivera M, Lingireddy A, Kalas MA, Ghafouri RS, Deoker A. A Rare Culprit of Methemoglobinemia. J Investig Med High Impact Case Rep 2022; 10:23247096221117919. [PMID: 35959982 PMCID: PMC9379961 DOI: 10.1177/23247096221117919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Methemoglobinemia is a rare cause of hypoxia and can be a diagnostic challenge
early in the disease course. The incidence of medication-induced
methemoglobinemia is more common than congenital-related methemoglobinemia. The
most common cause of methemoglobinemia is exposure to household detergents,
illicit drugs, or medications with nitrate or sulfonamide chemical groups. The 2
main medications accounting for up to 45% of medication-induced cases are
dapsone and benzocaine. We report a case of hypoxia and diarrhea with an
arterial blood gas (ABG) showing methemoglobinemia at 26%. Infectious and
autoimmune workup were negative. Methemoglobinemia level returned to normal
level within 2 weeks of hydrochlorothiazide discontinuation, suggesting
medication-induced methemoglobinemia at appropriate hypertension dosage. In this
case, there was an acute rise in methemoglobin levels following initiation of an
hydrochlorothiazide-losartan combination, which improved following the
discontinuation of hydrochlorothiazide. Extensive workup ruled out cytochrome b5
reductase (Cb5R) and Glucose-6-phosphate dehydrogenase (G6PD) deficiency, which
raised the suspicion of hydrochlorothiazide-induced methemoglobinemia, as it is
part of the sulfa drug family.
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Affiliation(s)
- Kahtan Fadah
- Texas Tech University Health Sciences Center, El Paso, USA
| | | | | | - M. Ammar Kalas
- Texas Tech University Health Sciences Center, El Paso, USA
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Preynat-Seauve O, Nguyen EBV, Westermaier Y, Héritier M, Tardy S, Cambet Y, Feyeux M, Caillon A, Scapozza L, Krause KH. Novel Mechanism for an Old Drug: Phenazopyridine is a Kinase Inhibitor Affecting Autophagy and Cellular Differentiation. Front Pharmacol 2021; 12:664608. [PMID: 34421588 PMCID: PMC8371461 DOI: 10.3389/fphar.2021.664608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/23/2021] [Indexed: 11/13/2022] Open
Abstract
Phenazopyridine is a widely used drug against urinary tract pain. The compound has also been shown to enhance neural differentiation of pluripotent stem cells. However, its mechanism of action is not understood. Based on its chemical structure, we hypothesized that phenazopyridine could be a kinase inhibitor. Phenazopyridine was investigated in the following experimental systems: 1) activity of kinases in pluripotent stem cells; 2) binding to recombinant kinases, and 3) functional impact on pluripotent stem cells. Upon addition to pluripotent stem cells, phenazopyridine induced changes in kinase activities, particularly involving Mitogen-Activated Protein Kinases, Cyclin-Dependent Kinases, and AKT pathway kinases. To identify the primary targets of phenazopyridine, we screened its interactions with 401 human kinases. Dose-inhibition curves showed that three of these kinases interacted with phenazopyridine with sub-micromolar binding affinities: cyclin-G-associated kinase, and the two phosphatidylinositol kinases PI4KB and PIP4K2C, the latter being known for participating in pain induction. Docking revealed that phenazopyridine forms strong H-bonds with the hinge region of the ATP-binding pocket of these kinases. As previous studies suggested increased autophagy upon inhibition of the phosphatidyl-inositol/AKT pathway, we also investigated the impact of phenazopyridine on this pathway and found an upregulation. In conclusion, our study demonstrates for the first time that phenazopyridine is a kinase inhibitor, impacting notably phosphatidylinositol kinases involved in nociception.
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Affiliation(s)
- Olivier Preynat-Seauve
- Laboratory of Therapy and Stem Cells, Department of Diagnostics, Geneva University Hospitals, Geneva, Switzerland.,Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Evelyne Bao-Vi Nguyen
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Yvonne Westermaier
- Pharmaceutical Biochemistry Group, School of Pharmaceutical Sciences, Faculty of Science, University of Geneva, Geneva, Switzerland
| | - Margaux Héritier
- Pharmaceutical Biochemistry Group, School of Pharmaceutical Sciences, Faculty of Science, University of Geneva, Geneva, Switzerland
| | - Sébastien Tardy
- Pharmaceutical Biochemistry Group, School of Pharmaceutical Sciences, Faculty of Science, University of Geneva, Geneva, Switzerland
| | - Yves Cambet
- READS Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Maxime Feyeux
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Aurélie Caillon
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Leonardo Scapozza
- Pharmaceutical Biochemistry Group, School of Pharmaceutical Sciences, Faculty of Science, University of Geneva, Geneva, Switzerland
| | - Karl-Heinz Krause
- Laboratory of Therapy and Stem Cells, Department of Diagnostics, Geneva University Hospitals, Geneva, Switzerland.,Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Sahu KK, Mishra AK, George S, Siddiqui AD. Cetirizine: Old Culprit or a New Member in the Family of Methemoglobinemia? J Pediatr Pharmacol Ther 2020; 25:167-168. [PMID: 32071593 DOI: 10.5863/1551-6776-25.2.167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Khan FA, McIntyre C, Khan AM, Maslov A. Headache and Methemoglobinemia. Headache 2019; 60:291-297. [PMID: 31724752 DOI: 10.1111/head.13696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2019] [Indexed: 11/27/2022]
Abstract
AIM This basic review is intended to summarize the current knowledge of methemoglobinemia as an important cause of secondary headache with the hope of generating a growing interest in studying this phenomenon. BACKGROUND We describe the pathological underpinnings of headaches generated by hypoxia. Possible mechanisms include cerebral vasodilation-associated stretching of the vessel nociceptors, sensitization of perivascular nociceptors mediated by nitric oxide, cerebral calcitonin gene-related peptide, activation of the cyclic adenosine monophosphate pathway, cortical spreading depression, disruption of the blood-brain barrier, and neurogenic inflammation. We review the clinical features, pathophysiology, and management of methemoglobinemia. We conducted a literature review of reports of symptomatic methemoglobinemia with headache. In addition, we describe a case report of a patient who presented with an acute onset of severe holocranial headache associated with rapidly progressive perioral paresthesia, cyanosis in lips and hands, nausea, and mild dyspnea on exertion. These features can be misinterpreted as an acute attack of migraine with pain-related hyperventilation syndrome and anxiety leading to clinically detrimental delay in the management of the progressive hypoxia. Her symptoms resolved following treatment with methylene blue. The complex relationship of migraine and hypoxia-related headaches is also reviewed. We propose that methemoglobinemia-associated headaches are possibly generated by stretching of the nociceptor nerve endings during cerebral vasodilation and hypoxia-mediated oxidative stress. CONCLUSIONS The case highlights the need to broaden the formulated differential diagnosis of an acute onset severe holocranial headache and pay careful attention to other signs and symptoms that may provide hints on potential mechanism(s) for secondary headaches. We provide justification for the need to incorporate "Headache attributed to Methemoglobinemia" as a subtype under the section "Headache attributed to hypoxia and/or hypercapnia" of the International Classification of Headache Disorders to support clinical decision making.
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Affiliation(s)
- Fawad Ahmed Khan
- The McCasland Family Comprehensive Headache Center, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA, USA.,The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA.,Tulane University School of Medicine, New Orleans, LA, USA
| | - Caley McIntyre
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA.,Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Abdul Mukhtadir Khan
- Department of Pulmonary and Critical Care Medicine, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Alexander Maslov
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA
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